Nitroglycerin: Routes and Adverse Effects – Organic Nitrates (Nursing)

00:01 Okay, if you've been following through with the videos, you have done the hard work.

00:05 Congratulations of learning a lot about nitroglycerin.

00:08 Now, this one is a pretty simple slide, I promise. It's a cool drawing, but this just tells you, "Wow, that's impressive.

00:16 We can give nitroglycerin lots of different ways." Sublingual, under the tongue; trans-lingual, in the mouth; oral, swallowing a pill; transdermal, a patch, or IV infusion.

00:31 So, that's a pretty complete list. We can give nitroglycerin in all those different routes.

00:37 Now, why do we pick what we pick? Let's break them down.

00:40 If you give it sublingual, that means right underneath the tongue, so you have the patient -- Okay, the next time you're looking at a mirror, I want you to look underneath your tongue.

00:51 There's a lot of blood vessels underneath there.

00:54 So it's an amazing place to absorb medications.

00:57 So, it will be absorbed directly from that oral mucosa right into the bloodstream.

01:02 You have to encourage your patients, don't chew the pill, don't swallow the pill.

01:07 It needs to melt right underneath their tongue.

01:10 It bypasses the liver initially, so we don't have to deal with first pass effect.

01:14 That's really cool.

01:16 That's why those nitro pills are really, really tiny because that dose gets -- boom, right into the bloodstream.

01:22 The patient will feel the effect in 1 to 3 minutes, so sublingual routes are really fast, whether we're giving nitroglycerin, or another medication we can give sublingual are antinausea medications. That's awesome because who wants to swallow anything when they feel nauseated, and you definitely want relief, quick.

01:42 So sublingual is really, really quick. It bypasses the liver.

01:45 We're not dealing with first pass effect. And here's the rule.

01:49 If someone has chest pain, and they have a prescription for nitroglycerin or it's been ordered, you give 1 tablet -- First of all, you get their level of pain, 1 to 10.

01:57 You give 1 tablet -- underneath the tongue.

02:01 You wait 5 minutes. You assess what their level of pain is.

02:04 You would expect that it would be lower, but if it's not relieved, you give another tablet.

02:10 Wait another 5 minutes, reassess, and then give a third tablet.

02:15 Now, if after 5 minutes after the third tablet and that chest pain has not been relieved, then you need to progress and go to an emergency room.

02:23 So that's the rule; 1 tablet every five minutes up to 3 doses. If that doesn't relieve the chest pain, now we're progressing to unstable angina, okay? That's 1 of your signs and symptoms.

02:35 So, you want to educate your patients that, "Hey, after 3 tabs, if that doesn't work, you need to immediately come in for healthcare." Now, translingual. It's really important that they don't get this mixed up with an inhaler.

02:48 You don't want them to -- inhale the spray.

02:50 It's absorbed right from the oral mucosa into the bloodstream, same thing.

02:54 It's not effective if they try and swallow it.

02:57 It needs to be absorbed in the mouth, just like we did with sublingual.

03:01 So, translingual sounds a little different, but it's actually the same concept as sublingual.

03:06 Now, if we're giving an oral medication, that means you're swallowing it.

03:09 It's going into your GI tract.

03:12 This is more sustained release nitroglycerin.

03:15 So this wouldn't be something we would use for an acute attack.

03:18 I could use the sublingual or the translingual for an acute attack, but I would not use oral because it's sustained release.

03:25 It takes a long time.

03:27 So we just use it for prophylaxis. And when you see that term, that's meant to, "I want to try and minimize the number of attacks that you have in the future." It won't deal with an attack right now.

03:37 So, underline the word "prophylaxis." Make sure you're very clear on the definition.

03:44 Write that in your own words, so we know that it's not for acute treatment, it's for preventative, or prophylactic treatment only.

03:53 Now, the drawback to sustained release or prophylactic treatment is with this type of nitroglycerin, you have an increased risk of developing tolerance.

04:03 So we want to be really careful with this. We don't usually use this without really keeping an eye on is the patient developing tolerance? Well, how would we know that they're developing tolerance? Well, the doses of nitroglycerin would no longer be effective, or we start having more breakthrough things happen.

04:19 So, this is the dose or this is the route that can really have a risk for increasing tolerance.

04:25 When we talk about patches, one of the things that we deal with with patches is we make sure the patient removes that patch every day, so it minimizes the risk of tolerance.

04:35 Well, let's break these down a little more.

04:37 Nitroglycerin patches, they're real sticky, and they put them on their chest wall.

04:43 It's important when they take the patches off, they rotate sites.

04:47 Now, when I had to be on a blood pressure medication that was a patch, I was on Clonidine, my skin did not like the adhesive at all.

04:55 So you could see where every patch had been for the last several months, all the way around on my body. So, some patients may be sensitive to the adhesive.

05:04 But when you put a patch on, it's the body heat that will slowly release and absorb it through the skin and into the bloodstream.

05:11 So, remember, sublingual was superfast.

05:14 Patches are much slower to kind of get into the bloodstream.

05:18 It takes 30-60 minutes.

05:20 Remember, sublingual could start in as quick as 60 seconds.

05:25 So they put it on once a day and it's really a problem for gentlemen who are hairy.

05:30 So they can't apply the patch over hair, otherwise, it just kind of hovers over the skin.

05:35 We need to have really tight and close contact to skin, so some people even have to shave a little spot on where you can put a patch.

05:42 So I'd already talked about rotating sites because that can be a problem if you have a difficulty with the adhesive like I do.

05:49 And you want to be patch-free 10-12 hours is great, but at least 8 hours and usually we do it at night, unless that's when you're having chest pain.

06:00 So, one question for you.

06:03 Why do we have patients take their patches off, usually at night, every day? Okay, I hope you got the answer.

06:11 We have them take their patches off because you want to reduce the risk of developing tolerance.

06:17 Now, IV nitroglycerin has a little bit different use.

06:20 It's a really short duration, so it has to be given continuously if you're going to give it the IV route.

06:26 You can't just walk in and give them a shot of nitroglycerin.

06:28 You hang an IV bottle of nitroglycerin and they have a continuous infusion.

06:33 So, it's rarely used to treat chest pain.

06:35 It's used with heart failure or with heart attack, or maybe to try to deal with your blood pressure during surgery, but this is not something that you're going to regularly see used.

06:47 It's rarely used to treat chest pain unless we've got it becoming very, very complicated.

06:52 Now, remember, that means like the patient has congestive heart failure.

06:55 They definitely have an MI, an infarct.

06:58 They're having a hard time controlling their blood pressure during a surgery, or they just have such uncontrolled chronic angina on a big attack, they might go to that. But that's a sign to you.

07:09 If we have to hang IV nitroglycerin to control a patient's chest pain, this is really a significant event.

07:15 You have to watch them on a monitor if you have them on IV nitroglycerin.

07:18 You want to watch their heart rate and you want to watch their blood pressure very, very closely.

07:23 Remember, this causes that venous dilation, so it can really drop their blood pressure.

07:27 And if you want to talk about a headache, IV routes can really give your patient a headache.

07:33 It also needs some special IV tubing. That's just a little fun fact, a little trivia for you about IV nitroglycerin.

07:40 So, this is not a great sign when you see this for treating chest pain.

07:45 If we have to use an IV drip, things have not gone well.

07:49 And I've listed the other reasons that you'd use IV nitroglycerin, during surgery or really complex cases.

07:56 Okay, this slide is our gift to you.

08:00 This is a slide that summarizes lots of things that we talked about.

08:04 So, look at this. For acute angina treatment, I'd consider sublingual or translingual.

08:11 For long-term prophylaxis, patches, ointments, which you really don't see very much anymore, or sustained release oral capsules.

08:20 These are not appropriate for acute angina, but they helped me with long term to prevent angina attacks.

08:25 And then also, you'll see on the end, abort an ongoing attack in anticipation of exertion.

08:30 So, if I'm going to do something that I know risked chest pain, I can actually take sublingual or translingual before I go through that experience.

08:38 So, this slide is really important for you.

08:41 Make sure you highlight it in your notes.

08:44 And when you walk through this slide, the most effective way to do it is say -- All right, put your finger on 1 of the routes and say, "What do I remember? Would we use this for acute or would we use this for long term?" So that's step 1.

08:55 Just work your way through with covering up the answers.

08:58 "Would I use this for acute or would I use this for long term?" and make sure you're solid on that concept.

09:10 Next, find a blank spot in your note and write "acute" and "long term," and see if you can come up with the different routes without looking at your notes.

09:26 Okay, I hope you're following our tips and strategies, not because we want to boss you around and tell you what to do, but because we know these are research-based strategies that will help you encode that information in your brain.

09:38 And you've probably heard me say that before in other videos, but I am passionate about this.

09:42 I want to help students use the small amount of time that they have available with all your life's responsibilities to really understand these concepts.

09:51 If you follow along with us and try these things, they might feel uncomfortable, but that's awesome. Because remember, the struggle is where the learning happens.

10:01 Okay, there's the red box.

10:03 So the adverse effects under nitroglycerin, we've got about 3 main ones for you to think of. First one, headache.

10:11 Now, it should get better after the patient is on nitroglycerin over a period of time.

10:15 You can use Tylenol or some other mild analgesic to deal with the headache.

10:19 Second thing orthostatic hypotension, that means because the -- it's a venous dilator, the blood will pool in your veins and your blood pressure will fall, and so will you.

10:29 So remind your patients, if they're going from lying to sitting, sitting to standing, do it slowly, and kind of wait for your body to acclimate when you first go to sitting. Sit there for a little bit, and when you stand up, stand there for a little bit.

10:42 Make sure you have something to brace yourself in case you get dizzy.

10:45 Because I know when I was on certain blood pressure medications, if I hopped up too quickly, wow, the whole world spinned around. It felt like I was on a carnival ride.

10:53 So adverse effects: headache, hypotension, and you're gonna have a heart rate problem.

11:00 So there are 3 H's for you with nitroglycerin: headache, hypertension, and heart rate.

11:08 So draw yourself 3 capital letters right there in the side, so you can remember.

11:12 You might even put them right on the bottle, that'd be a cool place to put them.

11:15 You have reflex tachycardia. Your heart rate gets really fast because your body is compensating for that drop in blood pressure.